“Total arterial devascularization first” technique for resection of pancreatic head cancer during pancreaticoduodenectomy

Abstract

Integrated resection of the pancreatic head is the most difficult step in radical pancreaticoduodenectomy (RPD) in patients with the portal vein (PV) and superior mesenteric vein (SMV) invasion or oppression by the tumor. This study introduced a new idea and skill named the “total arterial devascularization first” (TADF) technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta (AA) by completely transecting neural and connective tissue between superior mesenteric artery (SMA) and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h (ranging 4.5–8.1 h). The median intraoperative blood loss was 450 mL (ranging 200–900 mL). No intraoperative and postoperative bleeding of pancreatic head region occurred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical approach for RPD.

Keywords

pancreatic head tumor / pancreaticoduodenectomy

References

[1] GooikerGA, van der GeestLG, WoutersMW, et al.. Quality improvement of pancreatic surgery by centralization in the western part of the Netherlands. Ann Surg Oncol, 2011, 18(7): 1821-1829

[2] La TorreM, NigriG, FerrariL, et al.. Hospital volume, margin status, and long-term survival after pancreaticoduodenectomy for pancreatic adenocarcinoma. Am Surg, 2012, 78(2): 225-229

[3] TurriniO, EwaldJ, BarbierL, et al.. Should the portal vein be routinely resected during pancreaticoduodenectomy for adenocarcinoma?. Ann Surg, 2013, 257(4): 726-730

[4] Correa-GallegoC, BrennanMF, D’AngelicaMI, et al.. Contemporary experience with postpancreatectomy hemorrhage: results of 1,122 patients resected between 2006 and 2011. J Am Coll Surg, 2012, 215(5): 616-621

[5] WangM, ZhuF, WangX, et al.. A modified technique of end-to-end pancreaticojejunostomy with transpancreatic interlocking mattress sutures. J Surg Oncol, 2013, 107(7): 783-788

[6] ZhuF, WangM, WangX, et al.. Modified technique of pancreaticogastrostomy for soft pancreas with two continuous hemstitch sutures: a single-center prospective study. J Gastrointest Surg, 2013, 17(7): 1306-1311

[7] MalleoG, MarchegianiG, SalviaR, et al.. Pancreaticoduodenectomy for pancreatic cancer: the Verona experience. Surg Today, 2011, 41(4): 463-470

[8] WangH, ChenT, WangH, et al.. A systematic review of the physiological and operative severity score for the enumeration of mortality and morbidity and its portsmouth modification as predictors of post-operative morbidity and mortality in patients undergoing pancreatic surgery. Am J Surg, 2013, 205(4): 466-472

[9] WangSE, ShyrYM, SuCH, et al.. Palliative pancreaticoduodenectomy in pancreatic and periampullary adenocarcinomas. Pancreas, 2012, 41(6): 882-887

[10] JingW, HeT, HuX, et al.. The clinical efficacy and safety of modified Miwa’s augmented regional pancreatoduodenectomy in the treatment of ductal adenocarcinoma of the pancreas in the uncinate process. Hepatogastroenterology, 2012, 60(122): 268-272

[11] WrightFC, FitchM, CoatesAJ, et al.. A qualitative assessment of a provincial quality improvement strategy for pancreatic cancer surgery. Ann Surg Oncol, 2011, 18(3): 629-635

[12] PessauxP, MarzanoE, RossoE. A plea for the artery-first dissection during pancreaticoduodenectomy. J Am Coll Surg, 2010, 211(1): 142-143

[13] ShrikhandeSV, BarretoSG, BodhankarYD, et al.. Superior mesenteric artery first combined with uncinate process approach versus uncinate process first approach in pancreatoduodenectomy: a comparative study evaluating perioperative outcomes. Langenbecks Arch Surg, 2011, 396(8): 1205-1212

[14] AddeoP, MarzanoE, RossoE, et al.. Hanging maneuver during pancreaticoduodenectomy: a technique to improve R0 resection. Surg Endosc, 2011, 25(5): 1697-1698

[15] SanjayP, TakaoriK, GovilS, et al.. “Artery-first” approaches to pancreatoduodenectomy. Br J Surg, 2012, 99(8): 1027-1035

[16] KurosakiI, MinagawaM, TakanoK, et al.. Left posterior approach to the superior mesenteric vascular pedicle in pancreaticoduodenectomy for cancer of the pancreatic head. JOP, 2011, 12(3): 220-229

[17] BerselliM, SpertiC, BallottaE, et al.. Pancreaticodu-odenectomy with unusual artery reconstruction in a patient with celiac axis occlusion: report of a case. Updates Surg, 2010, 62(2): 117-120

[18] WeitzJ, RahbariN, KochM, et al.. The “artery-first” approach for resection of pancreatic head cancer. J Am Coll Surg, 2010, 210(2): e1-e4